Payor Disputes
Disputes with private insurers, Medicare Advantage plans, and Medicaid MCOs over claim denials and recoupments.
The Credible Allegation of Fraud Standard in Medicaid Enforcement
A thin, unverified referral can trigger a mandatory Medicaid payment suspension. Here is how states define a credible fraud allega…
UPIC Audits Explained: The Fraud-Focused Medicare Contractor
UPICs investigate suspected Medicare and Medicaid fraud, not payment accuracy. What a UPIC letter means and how its mandate differ…
Medicaid Exclusion and Termination: Collateral Consequences of an Audit
A state Medicaid termination for cause can trigger mandatory cross-state termination and federal OIG exclusion. What physicians sh…
When to Engage a Medicare Audit Attorney
The points in a Medicare audit where legal exposure escalates: extrapolated demands, prepayment review, fraud referrals, and revoc…
Responding to a Medicare Additional Documentation Request (ADR)
Medicare ADR deadlines run 45 days for MAC, RAC, and SMRC requests, 30 days for UPIC requests. What a complete response package mu…
Qlarant UPIC Audits: Jurisdiction and Process
Qlarant runs UPIC fraud investigations across the Western and Southwestern jurisdictions. What triggers a review, what the samplin…
Responding to a UPIC Records Request
A UPIC records request starts a 30-day clock, demands a complete production, and requires a privilege review most practices skip u…
State Medicaid OMIG Audits: Process and Defense
How New York's OMIG audit process works: records demands, the six-year lookback, extrapolation, and the 60-day window to appeal a…
CERT Audits and Error Rate Findings: The Provider Response
How the CERT program samples Medicare claims, calculates the error rate, and what a provider must do after an improper payment fin…